The Opioid Epidemic: Implications for MCH Populations

May 2017

Issue Br ie f

AS S O C I AT I O N O F M ATE R N AL & C H I L D H E AL TH P R O G R AM S

The Opioid Epidemic: Implications for MCH Populations

Introduction Overview State Title V professionals are front-line witnesses to the national opioid

epidemic and its effect on women of reproductive age, infants, children and

families. This issue brief provides an overview of the scope of the epidemic,

national policy efforts to address it, and state and local strategies for opioid

abuse prevention and treatment among MCH populations through the

Maternal and Child Health (MCH) Services Block Grant under Title V of the

Social Security Act.

Background

Opioid use accounted for 63 percent of the more than 52,000 accidental

drug overdose deaths in the United States in 2015.i The Centers for Disease

Control and Prevention (CDC)

estimates that in 2017, 91 Americans

will die every day from opioid

overdoseii. Limited access to health

and behavioral health care services,

inaccessible drug treatment and

inappropriate prescribing practices, as

well as social factors such as

unemployment and poverty, are contributing factors to the country’s worsening opioid

crisis.iii

Opioid use among adolescents and women of reproductive age is on the rise and is

adversely affecting the health and well-being of these populations. Adolescents, many of whom are unaware of the risks

associated with nonmedical opioid use, often become addicted through casual sharing of prescription pain relievers.iv For

women, the rate of deaths from prescription overdoses increased nearly 400 percent between 1999 and 2010, and the

rate of deaths from heroin overdose tripled between 2010 and 2013.v Moreover, opioid addiction often leads to other

medical issues that have societal impacts, including life-threatening infections, tuberculosis, and sexually transmitted

diseases such as syphilis, chlamydia, hepatitis and HIV/AIDS.vi

The financial consequences of the opioid epidemic are staggering. According to the U.S. Department of Health and

Human Services (HHS), the cost related to opioid use is approximately $55 billion, $20 billion of which is spent on

emergency room and inpatient care for opioid overdoses.vii

The AMCHP Role

AMCHP supports state maternal

and child health programs and

provides national leadership on

issues affecting women and

children. We work with partners at

the national, state and local levels to

promote women’s health; provide

and promote family-centered,

community-based, coordinated care

for women and children; and

facilitate the development of

community-based systems of

services for women, children and

their families.

The Opioid Epidemic: Implications for MCH Populations 2

Neonatal Abstinence Syndrome

Of special concern for MCH advocates is the growing prevalence of opioid use during pregnancy. Although it is not

uncommon for prescription opioids to be used during pregnancy to manage pain, inappropriate use can lead to adverse

outcomes for infants. Neonatal abstinence syndrome (NAS) is a postpartum drug withdrawal condition that is most

commonly associated with maternal use of illicit or prescription opioids.viii A cluster of NAS health symptoms occurs when

newborns withdraw from opioids, such as excessive crying, difficulty sleeping and eating, irritability, and convulsing. ix

According to the National Institute on Drug Abuse (NIDA), between 2000 and 2012, the number of infants born with NAS

increased fivefold. A child is born every 25 minutes in the U.S. suffering from opioid withdrawal.x Use or misuse of

prescription or illicit opioids during pregnancy can also lead to other adverse birth outcomes, such as low birth weight,

prematurity, small head circumference, sudden infant death syndrome (SIDS), and developmental and behavioral issues.xi

Child welfare implications

The epidemic’s impact on families is also reflected in the rising number of custodial changes for children with parents

struggling with opioid addiction. In these situations, federal law requires children to be placed in the custody of relatives to

minimize trauma. In 2015, nearly three million children in the U.S. were placed in the custody of grandparents, many due

to their parents’ opioid addiction.xii The demands of raising grandchildren can be overwhelming, and custodial

grandparents thus face many stressors. It is commonly reported that grandparents are no longer eligible for senior

housing programs because they are taking care of grandchildren, and in some situations children are even placed in out-

of-family foster care because of the grandparents’ health or financial limitations. In many states, grandparents are

ineligible for support services and financial assistance, although these supports are available to non-family licensed foster

care parents.

Federal and State Response The rising rate of opioid overdoses and deaths is viewed as a national public health emergency, and resources have been

galvanized at the federal and state levels to respond to this crisis.

National Policy Levers

21st Century Cures Act

Signed into law in December 2016, the 21st Century Cures Act appropriated $1 billion in opioid grant program funding to

states to address the opioid epidemic. The Substance Abuse and Mental Health Services Administration (SAMHSA) will

distribute the funding for state programs that can include public health-related activities, such as substance misuse and

abuse prevention programs; evaluation efforts to identify effective strategies; state prescription drug monitoring programs;

training for health care practitioners on opioid prescribing guidelines and on treatment referral; and expanded access to

addiction treatment.xiii

Comprehensive Addiction and Recovery Act of 2016

The Comprehensive Addiction and Recovery Act (CARA), signed into law in July 2016, creates, modifies, or reauthorizes

several federal programs to address primary prevention, addiction treatment services, and criminal justice and law

enforcement provisions. Examples of authorized provisions include state demonstration grants for comprehensive opioid

response, improving access to drug treatment, evidence-based prescribing practices, prescription opioid and heroin

treatment, and intervention demonstrations. In addition, Title V of CARA – entitled Addiction and Recovery Services for

Women, Families, and Veterans – includes the following specific sections focused on pregnant women, infants, and

family-based carexiv:

Sec. 501 – Improving Treatment for Pregnant and Postpartum Women: This section authorizes the

creation of grants to expand states’ services for pregnant and postpartum women suffering from a

substance use disorder.

The Opioid Epidemic: Implications for MCH Populations 3

Sec. 503 – Infant Plan of Safe Care: Amends portions of the Child Abuse Prevention and Treatment

Act relating to the development of best practices of plans of safe care for infants born substance

exposed or with withdrawal symptoms. This section also requires that a state plan ensure the safety

and well-being of infants released from care by addressing the health and substance use disorder

treatment needs of the infant and family/caregiver.

State Targeted Responses to the Opioid Crisis Grants

In December 2016, the SAMHSA Center for Substance Abuse Treatment and Center for Substance Abuse Prevention

released a funding opportunity announcement for states to address the opioid crisis. The purpose of the funding is to: 1)

increase access to treatment, reduce overdose-related deaths through prevention, reduce unmet treatment needs, and

support treatment and recovery activities; 2) supplement current opioid activities in state agencies and territories; and 3)

support comprehensive responses to the opioid epidemic using strategic planning and needs/strengths assessments.

The grants will be awarded to states and territories through a formula that is based on unmet treatment needs for opioid

abuse or dependence and on the number of drug poisoning deaths. The awards of these grants in 2017 will provide an

important opportunity for Title V MCH Services Block Grant programs to partner with state substance abuse programs to

combat the opioid epidemic. Title V MCH Services Block Grant programs are especially well-positioned to bring expertise

regarding the impact of opioids on the MCH population and to advocate for broader use of effective prevention and

intervention programs currently undertaken by MCH agencies.

Affordable Care Act

Several provisions within the Affordable Care Act (ACA) as it now stands can be used as opportunities to address the

opioid epidemic. They are as follows:

• Access to coverage. Through the creation of the health insurance marketplace and the expansion of Medicaid,

millions of individuals have gained access to health insurance and thus have gained access to options for

treatment and prevention. Additional information on Medicaid levers that can be used at a state level can be found

through a Robert Wood Johnson Foundation report, Medicaid: States’ Most Powerful Tool to Combat the Opioid

Crisis

• Essential Health Benefits (EHBs). The ACA requires that all plans sold on the health insurance marketplace and

all new Medicaid expansion plans provide a comprehensive set of EHBs. As a result, EHB-compliant plans must

provide mental health and substance use disorder services, including behavioral health treatment that features

counseling and psychotherapy.xv

• Home visiting programs. The ACA provided funding for the Maternal, Infant, and Early Childhood Home Visiting

(MIECHV) program. Home visiting programs are increasingly utilized by Title V MCH Services Block Grant

programs to address the opioid epidemic by connecting clients to services, treatment, and prevention education.

SAMHSA Policy Resource Guide

SAMHSA recently published A Collaborative Approach to the Treatment of Pregnant Women with Opioid Use Disorders. This report provides guidance to states and communities for developing collaborative, interagency policies and practices that can support the health, safety, and recovery of pregnant women with opioid use disorders and their infants.xvi This resource highlights strategies and tips on building a collaborative team and includes several facilitator guides.

The Opioid Epidemic: Implications for MCH Populations 4

State-Level Efforts

States are responding to the opioid crisis with innovative approaches that involve stakeholders at all levels, including

governors, state legislators and health care providers, as well as public health, mental health and substance abuse

agencies. Several of these activities are undertaken through the support of federal grants.

State Substance Abuse Agencies

Each state and jurisdiction has a lead agency that manages the federally-sponsored Substance Abuse Prevention and

Treatment Block Grant, which funds drug abuse prevention, treatment and recovery programs, and is charged with

upholding standards of care and data reporting. Title V MCH Block Grant Services programs can serve as essential

partners with state substance abuse agencies, as they expand programs to address the opioid crisis with the recent

infusion of additional federal dollars (as described above). A directory of Single State Agencies and other state-level

contacts for substance abuse is available here.

Prescription Drug Monitoring Programs

Prescription drug monitoring programs (PDMPs) are state-run databases that monitor and track prescribing patterns for

controlled prescription drugs, including prescription pain medication, to help identify suspected abuse or misuse (including

illegal use). This information helps clinicians and pharmacists identify and protect high-risk patients, provide early

intervention, and inform and improve opioid prescribing practices. Through partnerships and coalitions, several Title V

MCH Block Grant Services programs are engaging with PDMPs in their states. A list of contacts for state PDMPs can be

found at the PDMP Training and Technical Assistance Center.

State Legislation

Increasingly, states are passing legislation to combat the growing opioid crisis. For example in 2016 alone, several states

in the northeast, including Massachusetts, Vermont, Rhode Island, Connecticut, Maine and New York, have passed laws

related to prescription drug abuse prevention. The various state laws are designed to mandate a range of provisions that

engage clinicians, hospitals, insurers, and other stakeholders to address the multi-faceted opioid problem. Examples of

legal provisions include mandating providers to consult with PDMPs, requiring provider training in prescription drug abuse

prevention, reimbursing telemedicine providers for treatment services, mandating health insurance companies to cover

medication-assisted treatment, developing public education materials, and requiring hospitals to develop

policies/procedures and discharge planning. Several other states have either passed related legislation prior to 2016

and/or are enacting legislation in the calendar year 2017.

Opioid Antagonist Access Laws

Forty-seven states and the District of

Columbia have laws providing immunity

to medical professionals and individuals

who provide naloxone in cases of opioid

overdose. Naloxone is a drug, approved

by the Food and Drug Administration

(FDA), which can prevent the life-

threatening consequences of an opioid

overdose. Legislation has also allowed

for increased access to naloxone for first

responders and law enforcement

personnel.xvii

Map courtesy of NCSL

The Opioid Epidemic: Implications for MCH Populations 5

Good Samaritan Laws

Good Samaritan laws vary significantly

across states. However, 37 states and the

District of Columbia have passed some

form of legislation that provides immunity

for individuals either observing a drug-

related overdose or suffering from one who

call 911. The immunity laws generally

prevent arrest and prosecution for

possession and use of certain controlled

substances.xviii

Title V MCH Block Grant Services Program Strategies

Because opioid addiction so intimately affects women, infants, youth and families, state Title V MCH Block Grant Services

programs have made this epidemic a top priority. At least 16 states indicated opioids as a priority in the emerging issues

section of the Block Grant application. Title V programs are well-positioned to address the opioid epidemic through

partnerships and their work across sectors, and they offer a unique MCH lens that focuses on prevention and intervention.

The strategies outlined below provide a snapshot of the diverse ways in which Title V MCH Block Grant Services

programs are engaging other stakeholders to address this complex issue. After an initial keyword search in the Title V

Information System (TVIS), the following states were reached out to for strategies:

Workforce and Partnerships (8 states)

State Strategies for Title V MCH Block Grant Services involvement

Arizona Arizona Title V has convened a stakeholder group that consists of health care

associations and providers, administrators of health plans, public health leaders,

federal health care providers and mental health providers to develop consensus

guidelines to promote responsible and appropriate prescribing practices.

Kentucky Kentucky Title V participates in a workgroup to develop model hospital guidelines

for treatment and services for infants with NAS and their mothers. Activities include

distributing a checklist for hospital discharge planning to assure a smooth transition

to community services, identifying case managers for mothers and infants, and

coordinating services.

Massachusetts Massachusetts Title V collaborates with the Bureau of Substance Abuse Services

and the Perinatal Neonatal Quality Improvement Network of Massachusetts on a

number of initiatives, including the development of web-based resources for

pregnant women with substance use concerns and for obstetricians serving women

with opioid use disorders. Quality improvement partnerships are focused on

improving care for newborns with NAS and for families with maternal opioid use.

New Hampshire Since the passage of the federal CARA of 2016, the New Hampshire MCH program

Map courtesy of NCSL

The Opioid Epidemic: Implications for MCH Populations 6

is working diligently with partners, including the Governor's Commission on Alcohol

& Drug Abuse Prevention, Treatment & Recovery; the state DHHS Bureau of Drug

and Alcohol Services; the state DHHS Division of Children, Youth and Families; and

hospitals and birth attendants to develop a Safe Plan of Care for any infant affected

by illicit drug use or NAS, as required by the CARA legislation.

New Hampshire Title V works closely with public health entities, community-based

agencies and child welfare representatives to ensure supportive and integrated

services are available in the community to meet the needs of NAS infants and

mothers who are in treatment for their addictions.

New York State Title V participates in an interagency workgroup, led by the Office of Alcohol

and Substance Abuse Services (OASAS), to address the unique treatment needs of

pregnant women and parents with opioid use disorders.

State Title V represents the New York State Department of Health on an

interagency opioid surveillance workgroup, an outgrowth of the Governor’s Heroin

Task Force. The workgroup monitors opioid overdose deaths in the state and

regularly reports these deaths to counties. Furthermore, the workgroup has

developed a comprehensive website for Opioid-Related Data in New York State.

This database provides recent data and trends on opioid prevalence, healthcare

utilization (emergency department visits and hospitalizations), NAS and opioid use,

and mortality rates at the state, regional and county levels.

Tennessee Tennessee Title V participates in a NAS subcabinet working group composed of the

Tennessee Department of Public Health, Children’s Services, Human Services,

Mental Health and Substance Abuse Services, Medicaid and the Children’s

Cabinet. The working group convenes every two months to discuss state-level

policy and programmatic strategies to reduce the burden of NAS. The working

group jointly developed a letter to the commissioner of the U.S. Food and Drug

Administration encouraging the agency to adopt a warning label for narcotic

analgesics that could result in NAS.

Vermont

Vermont Title V serves on the Care Alliance for Opioid Addiction, a statewide

partnership of clinicians and treatment centers. The alliance has implemented the

Children and Recovering Mothers Team (CHARM) initiative. This SAMHSA model

program uses a regional approach involving a multidisciplinary group of agencies

serving women with opioid use disorders, and their families, from pregnancy

through the first year of infancy. The team provides women and families with

coordinated comprehensive care from the child welfare, medical (including

obstetrics and pediatrics) and substance use treatment communities. CHARM is

based on a model of early and ongoing intervention that includes identification of

substance use during pregnancy, engagement in prenatal care, medication-assisted

treatment, counseling, and education for families on caring for infants with prenatal

exposure to opioids.

Vermont Title V participates in the Vermont Child Health Improvement Program’s

Improving Care for Opioid-Exposed Newborns project, a partnership of the

University of Vermont, the Vermont Children’s Hospital and the state health

department. The collaborative program seeks to improve health outcomes for

opioid-exposed newborns through improved availability of, and access to, prenatal

and postnatal care for opioid-dependent pregnant women and infants; coordination

of services for women to connect them with substance abuse treatment providers;

The Opioid Epidemic: Implications for MCH Populations 7

and housing, newborn care, and resources to support mothers and families.

West Virginia West Virginia Title V is a founding member of the West Virginia Perinatal

Partnership, a multiagency, state collaboration that seeks to improve the health of

mothers and babies. The Partnership’s Substance Use During Pregnancy

Committee has developed an NAS toolkit, guidelines for substance screening and

testing of pregnant patients at outpatient visits (antepartum and postpartum), and

policy recommendations related to drug and alcohol use in pregnancy.

Data and Surveillance (5 states)

State Strategies for Title V MCH Block Grant Services involvement

Massachusetts In 2015, Massachusetts passed a law permitting the linkage and analysis of

different government datasets to better understand the opioid epidemic, guide

policy development, and help make programmatic decisions. This new model of

cooperative data analysis brings together government, academia, and private

industry. A number of analyses, which are led by Title V staff, are focused on the

MCH population.

New York New York Title V collaborated with other State Department of Health offices on a

study to assess the burden of maternal opioid use and NAS by geography, and

identify areas that require intervention.

New York Title V participates on the Metrics and Data Subcommittee of the

Interagency Opioid Overdose Prevention Steering Committee. This subcommittee

aims to share data and provide a platform for interagency communication to

address the prevention of opioid overdoses in New York.

Rhode Island Rhode Island Title V and other stakeholders track opioid overdose occurrences

(prescription and nonprescription) through emergency room visits.

Tennessee In 2013, the Tennessee Title V program worked with the State Health Officer to add

NAS to the state’s reportable diseases and events list. Elements of reporting

include case information, diagnostic information, and source of maternal exposure.

This reporting has led to a weekly surveillance summary of NAS throughout

Tennessee.

Wisconsin Wisconsin Title V has developed intra-agency data agreements to better

understand the scope and impact of the opioid epidemic in the state.

The Opioid Epidemic: Implications for MCH Populations 8

Policy and Program (7 states)

State Strategies for Title V MCH Block Grant Services involvement

Kentucky Kentucky Title V has collaborated with partners to implement legislation aimed at

expanding and improving treatment services and recovery supports.

Kentucky Title V participated in the development of the Center for the Prevention of

NAS, in partnership with universities and hospitals in Kentucky.

Kentucky Title V is collaborating with other state agencies and community partners

to implement two pilot projects to expand treatment services and increase capacity

for medication-assisted treatment and other recovery support services to pregnant

women and parents with opioid use disorder.

Massachusetts Massachusetts Title V participates in a legislative interagency task force on NAS

and substance-exposed newborns and a SAMHSA-funded substance-exposed

newborns policy academy to identify state resources, determine needs, and

develop a comprehensive plan to serve substance-exposed newborns and families

affected by NAS and maternal opioid use.

Massachusetts Title V participates in the implementation of a federal and state

partnership to expand medication-assisted recovery services to pregnant women,

paired with care coordination and peer recovery support.

Massachusetts Title V works with its partners to improve birth hospital referrals to

Early Intervention Part C (EI) for all newborns exposed to substances. The pilot

project seeks to increase family acceptance of EI referrals by providing an

engagement visit to families of babies with NAS early in their hospital stay,

participating discharge planning, and following up with families post-discharge to

ensure that an EI assessment has been completed. Additional supports for families

with maternal opioid use disorders are provided through MA Maternal Infant Early

Childhood Home Visiting programs that partner with treatment programs, the

Department of Children and Families and birth hospitals to identify and serve

families in need.

New Hampshire Using funding from the federal Cures Act of 2016, New Hampshire Title V works

closely with the state DHHS Bureau of Drug and Alcohol Services to bolster home

visiting programs in the state. Home visiting services provide an opportunity to keep

families in treatment programs and engage families in education to prevent the use

of illicit substances. Intervening early in childhood can alter the life course trajectory

of children in a positive direction. Social supports with a focus on family

relationships among families with young children can lead to healthy social-

emotional development and self-regulation, which can be protective factors against

drug use and other behavioral concerns.

New Hampshire Title V has worked closely with the state DHHS Bureau of Drug

and Alcohol Services to require all community health centers in New Hampshire –

including federally qualified health centers that provide adult and pediatric primary

care and perinatal care – to incorporate Screening, Brief Intervention, and Referral

to Treatment (SBIRT) services for all patients. The state DHHS Bureau of Drug and

The Opioid Epidemic: Implications for MCH Populations 9

Alcohol Services provided additional resources for workforce training and

infrastructure developments to improve electronic health records systems to better

support data collection and referrals.

New York New York Title V is actively engaged in the state’s multifaceted response to

stemming the tide of the opioid addiction and overdose problem, with a focus on

prevention, harm reduction, treatment, recovery, and law enforcement. Under the

Governor’s Heroin and Opioid Task Force, statewide initiatives include training first

responders to administer life-saving naloxone, limiting opioid prescriptions to seven

days, administering a statewide prescription monitoring program, and providing

mandated education for prescribers.

Rhode Island Rhode Island Title V has worked with other stakeholders to establish a health home

program for Medicaid enrollees with opioid use disorders.

Tennessee Tennessee Title V is actively involved in a department-wide initiative, the Primary

Prevention Initiative (PPI), which focuses its efforts on upstream primary prevention

strategies. In the East Tennessee region, one of the areas hardest hit by the opioid

epidemic, a major focus has been prevention of NAS. The East Tennessee PPI

Project provides health education classes and partners with local jails to refer

inmates to health departments for access to acceptable and effective family

planning services.

Vermont Vermont Title V supports the Medicaid Obstetrical and Maternal Support (MOMS)

program, which provides intensive, holistic, and comprehensive case management

services, including substance use treatment coordination, to pregnant Medicaid

beneficiaries.

Conclusion With the growing use of opioids among women of reproductive age, particularly among pregnant and parenting women, a

related rise in NAS, and far-reaching implications for youth and families, Title V programs see the direct impact of the

crisis on the populations they serve. Although there is no single strategy to address this very complex, multifaceted issue,

MCH/Title V programs are well-positioned to serve as key partners in efforts to protect the most vulnerable members of

our society, and share their knowledge and expertise to stem the tide of this nationwide epidemic.

Resources

• Association of Maternal & Child Health Programs (AMCHP): AMCHP 2017 Annual Conference Workshop

Recording: The Opioid Epidemic: Title V Strategies to Address the Growing Crisis

• Association of State and Territorial Health Officials (ASTHO): Neonatal Abstinence Syndrome: How States Can

Help Advance the Knowledge Base for Primary Prevention and Best Practices of Care

• Centers for Disease Control and Prevention (CDC): Prescription Drug Monitoring Programs

• National Center on Substance Abuse and Child Welfare: Substance-Exposed Infants: State Responses to the

Problem

• National Academy for State Health Policy (NASHP): Intervention, Treatment, and Prevention Strategies to

Address Opioid Use Disorders in Rural Areas: A Primer on Opportunities for Medicaid-Safety Net Collaboration,

• National Conference of State Legislatures (NCSL): Walking a Tightrope

• National Governors Association (NGA): Finding Solutions to the Prescription Opioid and Heroin Crisis: A Road

Map for States

• U.S. Department of Health and Human Services: The Prescription Drug & Heroin Overdose Epidemic

The Opioid Epidemic: Implications for MCH Populations 10

Acknowledgments AMCHP greatly appreciates and thanks the staff from state departments of health featured in this issue brief for their

valuable input. AMCHP thanks Debra Bercuvitz from the Division of Pregnancy, Infancy, and Early Childhood, Bureau of

Family Health and Nutrition, at the Massachusetts Department of Public Health, for review of the content.

This issue brief was made possible with funding support provided by the W.K. Kellogg Foundation. Its contents are the

sole responsibility of the authors and do not necessarily represent the official view of the W.K. Kellogg Foundation.

About AMCHP

The Association of Maternal & Child Health Programs is a national resource, partner and advocate for state public health

leaders and others working to improve the health of women, children, youth and families, including those with special

health care needs. AMCHP's members come from the highest levels of state government and include directors of

maternal and child health programs, directors of programs for children with special health care needs and other public

health leaders who work with and support state maternal and child health programs.

AMCHP builds successful programs by disseminating best practices; advocating on our member's behalf in Washington;

providing technical assistance; convening leaders to share experiences and ideas; and advising states about involving

partners to reach our common goal of healthy children, healthy families and healthy communities.

End Notes

i Rudd R.A., Seth P., David F., Scholl L. Increases in Drug and Opioid-Involved Overdose Deaths — United States, 2010–2015. (2016). Retrieved from http://dx.doi.org/10.15585/mmwr.mm655051e1 ii Centers for Disease Control and Prevention (CDC). Understanding the Epidemic. (n.d.). Retrieved from https://www.cdc.gov/drugoverdose/epidemic/ iii National Association of County and City Health Officials. (2017). State of the Opioid Epidemic: Local Public Health as the First Line of Defense. Retrieved from http://essentialelements.naccho.org/archives/5723 iv Center for Behavioral Health Statistics and Quality. (2016). Key substance use and mental health indicators in the United States: Results from the 2015 National Survey on Drug Use and Health (HHS Publication No. SMA 16-4984, NSDUH Series H-51) Retrieved from http://www.samhsa.gov/data/ v American Society of Addiction Medicine. (2016). Opioid Addiction Facts & Figures. Retrieved from http://www.asam.org/docs/default-source/advocacy/opioid-addiction-disease-facts-figures.pdf vi Center for Substance Abuse Treatment. Medication-Assisted Treatment for Opioid Addiction in Opioid Treatment Programs:

Substance Abuse and Mental Health Services Administration (US); 2005. (Treatment Improvement Protocol (TIP) Series, No.

43.) Chapter 10. Associated Medical Problems in Patients Who Are Opioid Addicted. Retrieved from

https://www.ncbi.nlm.nih.gov/books/NBK64167/ vii U.S. Department of Health and Human Services. (2016). The Opioid Epidemic: By the Numbers. Retrieved from https://www.hhs.gov/sites/default/files/Factsheet-opioids-061516.pdf viii Patrick S.W., Schumacher R.E., Benneyworth B.D., Krans E.E., McAllister J.M., Davis MM. Neonatal Abstinence Syndrome and Associated Health Care Expenditures United States, 2000-2009. JAMA. 2012;307(18):1934-1940. doi:10.1001/jama.2012.3951. Retrieved from http://jama.jamanetwork.com/article.aspx?articleid=1151530 ix Logan, B. A., Brown, M. S., & Hayes, M. J. (2013). Neonatal Abstinence Syndrome: Treatment and Pediatric Outcomes. Clinical Obstetrics and Gynecology, 56(1), 186–192. Retrieved from http://doi.org/10.1097/GRF.0b013e31827feea4 x National Institute on Drug Abuse; National Institutes of Health; U.S. Department of Health and Human Services, retrieved from https://www.drugabuse.gov/related-topics/trends-statistics/infographics/dramatic-increases-in-maternal-opioid-use-neonatal-abstinence-syndrome xi U.S. National Library of Medicine. (2015). Neonatal Abstinence Syndrome. Retrieved from https://medlineplus.gov/ency/article/007313.htm

The Opioid Epidemic: Implications for MCH Populations 11

xii Wiltz, T. (2016, November 02). Why More Grandparents Are Raising Children. Retrieved from http://www.pewtrusts.org/en/research-and-analysis/blogs/stateline/2016/11/02/why-more-grandparents-are-raising-children xiii U.S. Congress. (2016). H.R.34 - 21st Century Cures Act. Retrieved from https://www.congress.gov/bill/114th-congress/house-bill/34/text#toc-HF19AF43DF25C496A8701925628E61D97 xiv U.S. Congress. (2016). S.524 - Comprehensive Addiction and Recovery Act of 2016. Retrieved from https://www.congress.gov/bill/114th-congress/senate-bill/524/text xv Healthcare.gov. What Marketplace health insurance plans cover. Retrieved from https://www.healthcare.gov/coverage/what-marketplace-plans-cover/ xvi U.S. Substance Abuse and Mental Health Services Administration. A Collaborative Approach to the Treatment of Pregnant Women

with Opioid Use Disorders. HHS Publication No. (SMA) 16-4978. Rockville, MD: Substance Abuse and Mental Health Services

Administration, 2016. Retrieved from https://ncsacw.samhsa.gov/files/Collaborative_Approach_508.pdf xvii National Conference of State Legislatures. (2017, January 20). Drug Overdose Immunity and Good Samaritan Laws. Retrieved from http://www.ncsl.org/research/civil-and-criminal-justice/drug-overdose-immunity-good-samaritan-laws.aspx#Calling 911 xviii Ibid

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